Summary The Bell 206B III helicopter (registration C-GBKX, serial number2676) was departing Rservoir Gouin, Quebec, on a private visual flight rules flight to the pilot's cottage located 42nautical miles to the east-southeast. Shortly after take-off, at 0837 eastern daylight time, the aircraft struck the frozen, snow-covered surface of the lake. The pilot, the sole occupant on board, was fatally injured. The helicopter was destroyed. Ce rapport est galement disponible en franais. Other Factual Information The aircraft was owned and maintained by Hlicoptres Panorama (Panorama) based in Alma, Quebec. Panorama is a commercial helicopter company authorized to operate under PartVII, subparts 2and 3of the Canadian Aviation Regulations (CARs).The Bell206 pilot, fatally injured in this occurrence, was a friend of the company co-owner and would on occasion borrow the Bell206 for private use when it was available. The occurrence flight was a private flight. The co-owner, himself a fixed-wing and rotary-wing private pilot, also privately operates a Cessna206 fixed-wing aircraft. At 0700,1 the Cessna pilot and the Bell206 pilot called Panorama operations in Alma from the Bell206 pilot's cottage via satellite telephone, to get the weather conditions and forecast. It was partly sunny in Alma, 67nautical miles (nm) to the east; however, snow was expected by mid-morning. The weather at the cottage at that time was estimated 1to 3miles visibility in light snow showers, ceiling approximately 800feet above ground level (agl). The Bell206 was pre-flighted and the two pilots took off for Rservoir Gouin at approximately 0742to retrieve the Cessna, which had been stuck in the soft snow and slush-covered surface of the reservoir for over a week. The Cessna pilot was seated in the helicopter pilot's seat on the right-hand side of the helicopter; he flew the Bell206 from the cottage to Rservoir Gouin. His friend was seated in the front left passenger seat. Upon reaching the reservoir, the helicopter was flown along the north shore, instead of crossing over the expanse of the snow-covered reservoir. The Bell206 was landed slightly behind the parked Cessna, and the engine was shut down at approximately0807. The Cessna, flown by the company co-owner, took off for Alma without difficulty at0825. The weather at the time was estimated at 1miles visibility in light snow showers, ceiling 200feetagl. These weather conditions are considered to be instrument meteorological conditions (IMC). Under IMC weather conditions, pilots are required to operate under instrument flight rules.2 The Cessna pilot did not hold an instrument rating. The Bell206 pilot intended to take off within a few minutes and return to his cottage, 42nm to the east-southeast. While en route for Alma, the Cessna pilot attempted to communicate with the Bell206 pilot but did not get a response. The Cessna arrived in Alma at 0937. At 1000, when the Bell206 pilot did not return to his cottage as planned, Panorama was notified via satellite telephone. Panorama uses a Guardian SkyTrax (SkyTrax) flight-following system to track its helicopter fleet. The SkyTrax system showed, via the last global positioning system (GPS) position signal, that the Bell206 was still on Rservoir Gouin. The Cessna pilot boarded another helicopter flown by a company pilot and returned to Rservoir Gouin. The helicopter accident site was located at 1409, 1.2nm east of its take-off point on the flat, frozen, snow-covered surface of Rservoir Gouin. The pilot was fatally injured and the helicopter was destroyed. The weather at the time of the search was as follows: estimated ceiling 1500feetagl, vertical visibility approximately 800feet and horizontal visibility approximately 1mile, at times mile in constant moderate snow showers. Panorama pays for the SkyTrax system to record the aircraft's position every two minutes. The last SkyTrax system position was recorded at0836. It is estimated that the occurrence took place after 0836but before 0838since no GPSposition signal was received at0838. The helicopter struck the snow-covered surface of Rservoir Gouin on a northerly heading, in a 45nose-down, left-side low attitude. The helicopter struck the lake surface while in a high rate of descent. The main rotor blades struck the lake surface and the front cabin. The helicopter then tumbled, destroying the cabin sections and rupturing the fuel cell. The engine compressor and turbine casing deformation revealed signs of power at the time of impact. The main rotor transmission was not found. It is believed to have sunk in the soft snow and slush. Examination of the helicopter did not reveal any pre-existing mechanical abnormalities that could have contributed to the occurrence. The accident was not survivable because of the total destruction of the cabin area. There was no indication that incapacitation or physiological factors could have affected the Bell206 pilot's performance. The Graphic Area Forecast (GFA) weather charts showed a low-pressure system moving eastwardly across Quebec that would have affected the weather in the Rservoir Gouin area by early morning on 19March2008 (see AppendixA - Graphic Area Forecast (GFA)). The forecast predicted: Chibougamau and Roberval are the closest aviation weather reporting stations to the accident site location. The Aviation Routine Weather Report (METAR) at 0800 for Chibougamau, located 85nm north of the occurrence site, was as follows: The 0800 METAR for Roberval, located 80nm east of the accident site, was as follows: The Aerodrome Forecast (TAF) for Roberval valid at 0824 was as follows: The CARs4 applicable to minimum visual meteorological conditions (VMC) for visual flight rules (VFR) flight within uncontrolled airspace state that no person shall operate an aircraft in VFR flight within uncontrolled airspace unless the aircraft is operated clear of clouds and with visual reference to the surface. Where the aircraft is a helicopter and is operated at less than 1000feetagl during the day, flight visibility should not be less than 1sm, except if otherwise authorized in an air operator certificate or a flight training unit operator certificate- helicopter. Rservoir Gouin is a large, irregular-shaped body of water extending 55nm east-west and 40nm north-south. It is situated in ClassG uncontrolled domestic airspace. The irregular-shaped shoreline made up of multiple inlets, fingers, and islands makes it particularly difficult to navigate especially in poor weather. The weather at the time of the occurrence was fluctuating between VMC and IMC. The environment was conducive to whiteout conditions where the degree of contrast was low due to the overcast, obscure sky, flat light, reduced visibility in snow showers and the snow-covered reservoir. Upon taking off in an easterly direction, the pilot had a finger of trees as a reference below the helicopter and the expanse of the white snow-covered reservoir surface in front of him (see AppendixB- Site Diagram). Flight in whiteout conditions may result in a poorly defined visual horizon that will affect the pilot's ability to judge and stabilize aircraft attitude, or reduce the pilot's ability to detect changes in altitude, airspeed, and position. If visual cues are sufficiently degraded, the pilot may lose control of the aircraft or fly into the ground or surface of the water. A search of the TSB database for the period of January1998 to the end of December2007 revealed 18occurrences involving collision with terrain in whiteout conditions. These 18helicopter occurrences involved 45persons, 13of which were fatally injured and 23were injured. Studies5 have indicated that a majority of whiteout condition occurrences happen during VFRweather conditions where the pilot is justified in initiating the flight or chosen route but where visual cues are limited due to flat light, restrictions in visibility, overcast sky conditions and snow-covered terrain. In most cases, the pilot is unaware of a loss of visual references and a loss of control of the aircraft happens insidiously. The study did not indicate that low time pilots were more at risk of being involved in this type of occurrence in comparison with high time pilots. The pilot obtained a Canadian private helicopter pilot licence in May2005. His helicopter training was conducted on Robinson R22helicopters and he was endorsed on the Bell206 helicopter in November2005. He did not hold an instrument rating. The pilot's Category3 aviation medical certificate was valid at the time of the occurrence; he was restricted to day flying only, with operational two-way radio communications. It was not possible to confirm the pilot's experience on rotary-wing aircraft but it is estimated that he had approximately 130hours' total time; 85hours of which were completed on C-GBKX, the accident helicopter. The pilot also held a private fixed-wing licence obtained in May2001. The total number of hours on fixed-wing aircraft is unknown, but at the time of obtaining his helicopter licence, he had approximately 65hours on fixed-wing aircraft. Both the fixed-wing and helicopter training included five hours of instrument flight training, including unusual attitudes flight training. Flying in whiteout conditions is discussed during the ground school training, and if weather conditions permit, will be demonstrated during dual instruction on the helicopter. Because the Bell 206 pilot's training took place from March to May, it is likely that whiteout conditions could not have been demonstrated; this could not be verified during the course of the investigation. The helicopter was operated and maintained by Panorama's approved maintenance organization (AMO) in accordance with existing regulations and approved maintenance and inspection program. All mandatory airworthiness directives and required maintenance had been completed. Maintenance records indicate that the Bell206 had flown 13hours since the last 100-hour inspection and the annual inspection. No deficiencies had been reported. The helicopter's weight and centre of gravity were within the prescribed limits at the time of the occurrence. The Cessna pilot had flown the helicopter just minutes before and did not report any technical difficulties with the Bell206. The accident aircraft was not certified or equipped to fly under instrument flight rules nor was it required. The emergency locator transmitter (ELT) was mounted on the left front passenger window door frame. The unit was torn from its retaining brackets, the moulded plastic casing was damaged and the antenna connection was severed. Both the battery compartment and circuit board were damaged on impact, eliminating the possibility to transmit a distress signal and the wreckage location. Information from the Bell206's SkyTrax tracking system provided its last known position to the company, which helped locate the wreckage in a timely manner. The SkyTrax unit survived the impact forces, and information contained in memory provided a record of the aircraft's movements. The SkyTrax system service provider's database and operator's flight tracking records allowed investigators to review the morning flight from the Bell206 pilot's cottage to Rservoir Gouin, the time at which the pilot started the engine while positioned on Rservoir Gouin and the helicopter's last known position. On 13 March 2008, a similar helicopter occurrence (TSB occurrenceA08Q0053) took place at dusk in whiteout conditions over a large, frozen, snow-covered expanse of water. The pilot survived the accident with minor injuries; the helicopter was destroyed. In this occurrence, the ELT unit's moulded plastic casing was damaged and the antenna was severed. Post-accident testing of the ELT unit showed that, although the gswitch had been activated during the impact, the severed antenna rendered the unit incapable of transmitting an adequately strong emergency signal. The control tower at the airport from which the aircraft had just taken off, located five miles from the crash site, did not capture an ELT signal. Because the aircraft's SkyTrax tracking system was programmed to register its position every 15minutes, the aircraft's last known position was on engine start-up at the airport from which it departed. The review of radar data and the pilot's physical ability to use a cellular telephone after the crash assisted in locating the aircraft. Unlike the Rservoir Gouin occurrence, this occurrence took place close to a populated area. Confusion over the aircraft's last reported position, unknown safety of the lake's surface and reduced visibility in snow showers delayed timely rescue. The pilot managed to walk on the frozen lake surface towards the rescue units' flashing vehicle lights and was assisted by rescue personnel 2.5hours after the occurrence.